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Postpartum Psychosis: Diagnosis, Treatment, and Prevention (00:00)
Puder:
All right, welcome back to the podcast. I am joined today by Dr. Veerle Bergink. She is the director of Mount Sinai's Women's Mental Health Center and internationally renowned as an expert in psychiatric disorders in women. Her research started in 2008 when she established a prospective postpartum psychosis study, currently the largest first-onset postpartum psychosis and mania cohort in the world. She has a highly effective clinical treatment algorithm we're going to discuss today for acute phase and also prevention of postpartum relapse. And she has written tons of articles. She's someone who I've been excited to have on here, and so welcome to the podcast.
Bergink:
Yeah, very happy to be here.
Puder:
So I was thinking I would start with a case and then we would kind of add to the case or change the case slightly and then see how that might change how you might handle it. Okay?
Bergink:
Yeah, sure.
Early Signs and Symptoms of Postpartum Psychosis (00:59)
Puder:
Okay. So this is someone who has had no previous pregnancies, no mania, no depression, no psychosis. Day zero to two, she feels tired, happy, sleeping two to three hour stretches because of cluster feeds. [Her] Partner is not worried. On day three she cannot fall back asleep after 3:00 AM, [her] mind will not turn off, and [demonstrates] mild irritability when her mother suggests that she stops nursing so she can sleep. Day four, she's checking obsessively the baby's breathing. She tells her husband, “Something is wrong with her. I can feel it.” She's still organized, breastfeeding every two to three hours. On day five, there's some mood swings within hours. Tearful, then elated. She says she feels like she's been “chosen,” sleeps 90 minutes in 24 hours.
Puder:
Day six, [her] mood is incongruent, delusions appear. She says, "My husband wants to take the baby. He's not who he says he is.” Brief visual misconceptions of “a shadow over the crib." And then, day seven, she's brought in after she kicks her mother in the abdomen when the mother tries to take the baby so that she can sleep. Upon interview, she's pressured, grandiose. She's admiring of her ability to potentially nurse her baby for 24 hours straight. She's slightly disorganized, lacks insight, misrecognizes a nurse as a childhood friend, oriented to name but not date. Okay. So walk me through the case, what your thoughts are, how you're approaching this.
Diagnosis, Medical Workup, and Acute Treatment (02:36)
Bergink:
Yes. When I would see her I would keep it very short because women are usually very irritable and she sounds manic; and it's a very clear story that she has manic and psychotic features right after delivery. So the most important thing I would like to know is if she has ever had hypomania or mania before and whether she has a family history of bipolar disorder. After that, I would spend the time to establish a relationship with her to motivate her to be admitted as an inpatient so that we can do some diagnostics. I would reassure her and her husband, that we're thinking about postpartum psychosis, but that this is a very treatable condition and that I expect that her admission not to be too long, but that in my view, it is very important that she will get admitted so that we can check her blood to rule out somatic causes for psychosis and mania and that we can treat her so that she can be reunited with her baby as soon as possible.
Bergink:
So that would be my first step. So only very shortly speak to her and mostly spend time with her and her husband to explain that she has postpartum psychosis. One of the first things we should rule out is whether she has an infection and check her thyroid, whether she has postpartum thyroiditis, which can be a major trigger, as well. And then, you know, so do some, some broad standard metabolic lab work. And that is diagnostically the first step. And then I would explain to them sleep loss has also contributed, so that it's very important that we treat her for sleep. In Europe, we start with a few days only of sleep medication, but there we have mother-baby units, so we have a bit more time to treat moms because occasionally someone gets better with only two nights of good sleep.
Bergink:
But given that she had these symptoms now for many days in a row, I probably would start, if she could not be admitted with her baby, sleep medication together with antipsychotic medication to get her out of her mania and psychosis as soon as possible.
Puder:
Okay, perfect. Okay, so you start her with some, let's say, some Haldol and then….
Bergink:
Yes. Or a first-generation or second-generation [antipsychotic]. I would either start her on Haldol, we have seen many women getting better on Haldol, but also olanzapine is a good treatment option at bedtime. There is not much research to guide us here, as to what works. We basically know that all antipsychotics work if we dose them high enough in postpartum psychosis, as far as we know. But again, there is hardly any research supporting it, but that's my clinical experience.
Anti-NMDA Receptor Encephalitis and the Differential Diagnosis (05:55)
Puder:
Okay. So let's start, let's say you started the Haldol, or [another] antipsychotic, it doesn't matter. And soon after she develops rigidity, tremor, bradykinesia. What are you thinking at this point?
Bergink:
Well, yes, that obviously is a reason to not treat with first-generation antipsychotics, but that gives me also another reason to also look for NMDA (N-methyl-D-aspartate) antibodies because we know that these neurological soft signs, we see those more often with women with postpartum psychosis will have an underlying autoimmune encephalitis. And that is not that common. That's only a few percent of the cases with postpartum psychosis, but it needs to be ruled out. You can measure it in blood, but ideally you do a spinal tap, if you can motivate the patient to actually do that. So in this scenario, then I would switch her to olanzapine.
Puder:
Okay. So I was using one of your papers where you studied anti-NMDA receptor encephalitis, and the tell is that rigidity, tremor, bradykinesia after starting the antipsychotic (Bergink et al., 2015a).
Bergink:
Yes, absolutely. And those patients who had autoimmune encephalitis all had that. But the other way around, 30% of our patients on first-generation antipsychotics actually have some neurological subsciences. So it's not always, but it should be tested. And I think it should be tested in all women with postpartum psychosis because we know of NMDA encephalitis, but I think it could very well be, given that postpartum period is such a strong immune trigger, that there are way more women with an autoimmune encephalitis with unidentified antigen, if that makes sense (Bergink et al., 2015a). And, one of our research proposals is also to test this better because that actually has treatment consequences, right? That's just a different disease. If someone has postpartum autoimmune encephalitis is different from someone having a postpartum psychosis for which the cause is unknown.
Autoimmunity, Thyroid Disease, and Postpartum Mental Health (8:07)
Puder:
Okay. So during pregnancy, there's a huge immune system dampening, and then, after delivery, it just comes back, the immune system starts revving up again. Is that why you think there's an over-revving of the immune system and there's a lot of these autoimmune issues that come?
Bergink:
Yes, absolutely. I think that's very clear. Right? I mean, we know this from autoimmunities that almost all women do feel better after pregnancy, and have a high risk of relapse. And that is because, as you say, during pregnancy, the immune system is somehow suppressed, otherwise a mother’s [body] would reject her own child. It's, of course, not completely down because otherwise pregnant women would die of infection, and that is not happening at all. So it's just that the immune system is differently organized with a more prominent role for the innate, the very basic line for defense, and not so much a specific adaptive immune response. So the professor in immunology I work with says, you know, pregnant women have the basic immune system of a snail. So, very simple basic immune defense. So what happens after delivery is that the innate immunity is still high, and the adaptive T-cell mediated immunity comes back to where it was before.
Bergink:
So we see an immune stimulation, and that is why people with rheumatoid arthritis feel worse after delivery, with multiple sclerosis, with autoimmune thyroiditis, or they have their first onset after delivery, whereas pregnancy is protective. Well, in our very recent research, also in bipolar women, we looked at a register that pregnancy really seemed to be protective for first-onset mania. There are quite a few papers out now, and ours was this year. And also for severe depression, we see that that is lower than at other times. So, in particular within psychiatry, bipolar disorder seems to have the same pattern as autoimmunities, of pregnancy being protective and postpartum being in high-risk period. And why that is specifically for bipolar disorder and not for other diseases in psychiatry such as schizophrenia or OCD or whatever disease, ADHD, I don't know.
Bergink:
I think it gives us an important clue about the underlying nature of the disorder.
Puder:
Very interesting. Okay. So let's say there was some sort of autoimmune thyroid disease. Are you more hesitant to use lithium?
Bergink:
No, I would still treat her the same, because we do not know how to treat otherwise. Of course, lithium works on the thyroid, but via different mechanism. I think the most important thing is also monitoring the thyroid and referring to internal medicine doctors, and especially, you know, after autoimmune thyroiditis is typically characterized by first hyperthyroidism and then hypothyroidism. Right? And, all of these contribute to the psychiatric symptomatology. And, we need to monitor it, and if it really leads to clinical hypothyroidism, then the patients should get treated with thyroid supplementation. And that is very relevant. Also, for many women with postpartum depression, I've seen so many women in which physicians do not think about the thyroid and then it has such a major impact. And sometimes it also helps in the treatment of the women who have depression in addition to the postpartum thyroiditis, but it kind of helps them to understand that this contributes.
Bergink:
And I think that helps as well, because then I explain…I mean, often we do not know what causes it, right? But in this scenario, we know something that really likely contributed to not feeling mentally well. And that helps if I explain to women that most of these cases are transient and the thyroid gets back to normal and they will feel better and that we can also be very optimistic about their treatment of their postpartum mood disorder. So I think that's something most people do not know that actually postpartum depression is more easily treatable than depression at other times. So don't tell anyone, but our, our field is not that difficult. A lot of women actually do get better.
Recovery, Prognosis, and Risk of Bipolar Disorder (12:46)
Puder:
Yeah, that was some really interesting things from reading your papers. That, if this is treated, is very treatable. It's very treatable.
Bergink:
Yes. And both postpartum psychosis and postpartum depression. So postpartum psychosis [remission rates are] amazing. Like 98% get fully better. As in, really our criteria for getting better are strict. We published a paper this year, a letter in The American Journal of Psychiatry and, really no manic symptoms, no psychotic symptoms, but also, I don't know if you know the EPDS (Edinburgh Postnatal Depression Scale), that's a very simple postpartum depression rating scale, 10 items. And they had to be really low on that scale, as well. You and I, on a bad day, score higher than these women. So they were not only not manic and psychotic, but also not depressed after the acute phase (Bergink et al., 2025). And I think that is a very optimistic message to give, especially of course, in this time where there is so much attention for the potential, tragic consequences of postpartum psychosis.
Bergink:
And it's really discussed as a very difficult condition and a very high risk of suicide and infanticide. So there are so many myths out there, and I'm happy to be on this podcast because I think it's important to know that, in many cases, women get diagnosed in time and then it's a very treatable condition with a better prognosis than women would have if they had that at other times in their life, if that makes sense.
Puder:
Yes. So, from your research, what have you found in terms of women who do not have a history of bipolar, who have their first episode postpartum. So their first episode of postpartum psychosis occurs, what percentage of those women will not have recurrence?
Bergink:
Yes, in our own cohort, more than half. So, and those women are treated in an academic center, excellent care. They're treated with lithium, closely monitored. So, if we look at all studies done, ever, then, ours was quite recent, but all other studies are 30 years ago. Like, really old psychiatric literature. Then we see everywhere the same pattern: roughly half of women get better and remain well until they get pregnant again, have another delivery, and then they're at sky-high risk again. So those women really have a postpartum only illness. Whereas for other women, they have these episodes, and then they are treated with antipsychotics and lithium, and they try to taper lithium, but that doesn't work that well. They get depressed and they have more mood episodes in their lives. And then, in retrospect, this very severe postpartum episode was the first onset of a lifelong bipolar disorder.
Bergink:
And of course, we would like to answer that question for those women, being acutely ill, not only what causes it and how do we get her better as soon as we can, but also how can we prevent that disease course, right? Or, how can we at least know which women are at high risk for a lifelong bipolar vulnerability or mood disorder and which women have this postpartum-only disorder, which makes a big difference for them as well, right? But, unfortunately, the only way we can tell is by trying after one year to start tapering the medication. And in that sense, at least in my experience, I don't know what your experience is, but it's not so different from, you know, mania or active psychosis at other times.
Bergink:
If young people have this, they're treated, they're very sick, they get better. At some point, after they get better, they start asking themselves, "Do I need this medication long-term?" Right? Absolutely. And most people then, at some point, try to taper, and that's only the very hard way to figure out if you actually need it or not, because that means that you get sick, that means that you needed it. And at this point, we cannot tell which patient. Of course, we know some risk factors, but we really cannot tell which patients can safely taper or not, and especially for young people with bipolar disorder, that's a very difficult one. And same for the women I treat, right? I mean, these patients are a bit older, but not that old.
Bergink:
I think women [have] their first child in their 20s, beginning 30s, and then it's quite something to think about having to use medication long term.
Puder:
Okay, so it sounds like we've kind of talked about two categories. People with maybe a history of bipolar and first onset postpartum psychosis. And I think you also differentiated in your research, postpartum psychosis that comes out of more of a depressed picture, and it's usually a little bit of a slower to start. Can you talk about that a little bit?
Bergink:
Yes. So we try to figure out if women have depression with psychotic features, or if they only have psychotic symptoms, or if they're manic. Does that matter in terms of their treatment response? Does that matter in terms of their prognosis? Well, the short answer is no, as in all women get better, but women with depression with psychotic features, they have a longer disease episode than mania, and that's what we know from outside the perinatal period as well, right? The depression with psychotic features is usually not so easy to treat. That those episodes are a bit longer. We know that also women with depression with psychotic features, in the long term, it doesn't, at least in our research, doesn't make a difference in terms of their prognosis, whether they had a mania or a mixed episode or a depressed episode with psychotic features or a psychotic episode without much mood symptoms.
Bergink:
So in a way, the phenomenology doesn't seem to matter that much. It's more that, in some women, childbirth triggered a severe mental health disorder with a variety of symptoms, basically. If that makes sense.
Postpartum Depression, Bipolar Depression, and SSRIs (19:37)
Puder:
Does studying this make you hesitant to put a woman on an SSRI who's just depressed? You know, just more of the depressed picture?
Bergink:
If it's just depression I'm not hesitant to treat with an SSRI. It really depends on the course. We know that many women with postpartum depression honestly, already were depressed, either during pregnancy or even before. But there are also some women who develop new-onset depression after delivery, and then it really depends on the pattern. If a woman has a very sudden acute onset, very severe depression, in the early weeks after delivery without a clear trigger such as her baby being severely sick in the NICU or other disasters, then I'm really worried about bipolar depression, honestly. And that has been described, as well, quite extensively, that depressions occurring in a postpartum period are more often bipolar depressions than depressions at other times.
Bergink:
That is an odds ratio of two. So let's say, if you had depression, then you had a certain risk of that depression being the first onset of a bipolar disorder, but that won't happen to you. But if you had that depression postpartum, then the risk of that depression being bipolar depression is two times as high. So I think, in general, we should always be a bit cautious with SSRI in the postpartum period. And of course, we saw in the Lindsay Clancy case how horrible some people react to SSRIs, right? I've seen that more often. I have a case series of patients who really had psychosis or mania triggered by SSRIs in the postpartum period, and Verinder Sharma (2006), from Canada, has published on that as well.
Bergink:
So we know this. So we should also be a bit cautious. On the other hand, we should not let severe postpartum depression be untreated, of course. Sometimes I see both a lot of undertreatment of postpartum depression and overtreatments. And what I mean with overtreatment, if that is a woman, this first week postpartum, women have mood swings, they have low moods, but sometimes they have sleep loss. They are told, like, "Oh, if you see your baby, you're gonna feel amazing," and they don't experience that at all. They're low. And I have seen many women in which their healthcare provider immediately gave them an SSRI, as in the first week after childbirth or the second week. And I'm always very, not that fast, not so much in a hurry because you really want to see how that develops over time.
Bergink:
This is such a period of rapid changes, you see what I mean? And there is no need to, you know, acutely treat depressive symptoms with a SSRI. I think we should carefully see someone another time, see how it develops over time, really see if it's a depression, before we start.
Lithium for Postpartum Psychosis and Relapse Prevention (23:13)
Puder:
Okay. And, in your algorithm, you were doing the benzo (benzodiazepine), the antipsychotic, lithium, holding the lithium for nine months, right? But my question is, why not start the lithium right away? Or, how do you, like, in this patient that I told initially, why not immediately lithium?
Bergink:
After we published the papers, we really tried to change that clinical practice and start it earlier, so we're trying to do this now, and haven't published on it yet. But, especially in the US, lithium [does not have] a good name. I think that's not correct, you know, but people are really hesitant to use lithium. They have all kinds of [negative] associations with lithium. So it's not used enough. So it all also takes time, because lithium is something for the longer term, right? You're not going to use it very short. We know that antipsychotics have a more rapid anti-manic effect, honestly. So lithium is really for the long term, for this first year of postpartum. So you want someone to be well-informed and also motivated to actually take the lithium and to also understand why they need it.
Bergink:
Because it's important in the treatment of postpartum psychosis because the women, without lithium, we saw, unfortunately, that half of them relapsed within a year after delivery. And that is a problem. If you treat with electroconvulsion therapy, which some people say, "Okay, why shouldn't we treat immediately with ECT? You know, it's so severe, isn't that the fastest way?" Well, I'm not sure if that is faster than medication. And the problem is, ECT also gets women completely better, but then you still face the discussion, like, "Yeah, and now what?" You know? Then, I still would advise to start lithium for the first year postpartum, after the ECT course. You see what I mean? So that's why, if it was me, or if it was my sister, or my child, I would prefer lithium over ECT treatment.
Puder:
Yes. Yes. Okay. I want to share this from your study, which you were the first author of. An amazing study, showing days of remission to relapse. And the lithium, when I saw this, I was like, "Oh, my goodness, this is, this is incredible." And so what, for those who are listening to audio, maybe you can describe this figure once again and what it says (Bergink et al., 2015b).
Note. Reprinted from “Treatment of psychosis and mania in the postpartum period”, by Bergink et al., 2015b, American Journal of Psychiatry, 172(2), 120.
Bergink:
Yes. So the orange line are women who used lithium and antipsychotics in the acute phase. And the green line is women who only used antipsychotics. And it's good to understand that this was not a randomized control trial. So it's not that we randomized women, no. We offered antipsychotics and lithium during the acute phase, but some women recovered really fast, and those were women who only were on antipsychotics and we did not get to the point that we discussed lithium with them. And of those women, we also thought, “Okay, their disease episode was very short.” They recovered fast on antipsychotic only and we thought, "Well, perhaps we don't need to start lithium." But then we analyzed our data, and then we saw that those women, who were initially better off because they had a short episode and recovered really fast, were actually more often to have a relapse one year after delivery, which is, of course, not great because that means that after your depression with psychotic features, you have another depression or after your mania, you have this typical pattern.
Bergink:
Of course, women, we see this in bipolar disorder as well, women or people, patients getting out of their mania and have been stable for a while or sometimes even immediately going into a depression. And, we really see that lithium can prevent this pattern. So, we know that lithium works well at other times as well, but I don't know why lithium works especially well postpartum. Because we know at other times that lithium is not for everyone, right? There are also many people who are non-responders to lithium. Whereas, in a postpartum period, we don't see that that much.
Puder:
Yes. It's incredible to think, I mean, for those of you who can't see the picture, I'll just say, you can see that lithium, most of the people are not relapsing. Whereas the people who are not on the lithium, 50% relapse. That's a huge difference. So yeah, we need to bring back lithium. Make lithium cool again. Have some drug reps maybe in America bringing lithium in special-colored, expensive lithium pills. I'm joking.
Bergink:
Yes, I think that's the problem. It's so cheap. There's really no money to make with lithium. So that's why people are not arguing hard for treatments with lithium in general, right? Because other treatments were much more moneymakers. So, but I'm not sure if the ultimate solution is making lithium more expensive.
Puder:
No, I'm joking, I'm joking.
Bergink:
No, no, I know.
Puder:
So I just had a bipolar patient, just yesterday, who I had started on lithium two weeks before and he had seen many different psychiatrists and he had never been on lithium. He had been on five or six different antipsychotics. He had been on Depakote. He had been on lamotrigine. He had never been on lithium; and he was completely a different person two weeks later after starting lithium.
Bergink:
Yes, absolutely. And it's so weird because all our guidelines say that lithium is the first choice. So all guidelines say it, in different countries. Basically, no one is doing it, especially not in the US and it's interesting because, if you see, if you compare studies in the rest of the world, like Australia or Asia or Europe, bipolar studies to US patients, then in many studies, it has been shown that bipolar disorder in the US, the mortality is higher, people have more episodes. They are more on polypharmacy, as you say, using so many medications and yet being unstable. And I always thought, “That's just because, you know, in the US, less than 20% gets lithium. Whereas, in the rest of the world, more than half of the bipolar patients get lithium.
Bergink:
But, there are also some alternative theories out there. Back in the day, only the adventurous people emigrated to the US, right? So in order to emigrate, you had to be either miserable, depressed, or being in a hypomanic state to think it was a good idea to embark on that ship. So that, somehow in the US, we end up… and I might be one of those persons because I also emigrated from Europe to the US, for whatever reasons. I love it here, but that has been even proposed as the reason why we see worse outcomes here. Whereas, I sometimes think, well, I think the more likely explanation is that we don't follow the guidelines that much and treat with lithium, right? And, for my field, the problem is that we don't have inpatient mother-baby units, that also makes a huge difference.
Why the U.S. Needs Mother-Baby Psychiatric Units (31:18)
Puder:
Do you have a mother-baby unit at your current institution, or no?
Bergink:
No. We're looking for funding to start one. Like the first one in the US because we don't have them. We have them in Western Europe, in Australia, and in India is a very good one. And not in the US. And there are quite a few good day treatment centers, but not enough, not in every area in the country, only in California, in North Carolina, here in New York City. But in those units, babies cannot stay overnight. And that is a huge difference because women want to go home. Well, first of all, they don't want to be admitted, of course, to a psych ward, right? Most people don't want that, but especially not if you're separated from your baby. So here we get the weird situation that both patients and clinicians are kind of getting in a rush to make women better by throwing so many medications at them as in, you know, she needs to be reunited with her baby.
Bergink:
And we see that for both severe postpartum depression and postpartum psychosis. And that's just not helpful. Also women go home, and I can't blame them, nor their clinicians, before they are in full remission. So what happens, and we have those numbers out there as well, that women, you know, they're admitted to a psych ward, they go home while they're not fully recovered, and then they come home and they relapse again. And that leads, ultimately, of course, to readmissions and worse outcomes. So I'm a huge advocate of mother-baby units, but the problem is really the financing of the babies, because here in the US, insurance companies say we are not going to pay for healthy babies being in a hospital, basically.
Puder:
Yeah, I think if someone's listening to this and wants to fund your mother-baby unit, I'll put them in contact with you.
Bergink:
That would be amazing. Because we need that.
Puder:
We really, really need that.
Bergink:
We need that. It can have their name, everything. No, I think always the first step is most difficult because I think if we can show that we can open one such unit and that it works, and that mothers get better and also, honestly, that it saves money in the end, even if you don't care about mothers and you don't think babies are sweet, then still, and you only are interested in money, then still it's the cheaper option to society to have a mother-baby unit.
Puder:
Well, because it's cheaper because of future outcomes, right? And that's the problem.
Bergink:
Oh, everything. Yes, the mother doesn't go back to work, you know, if she has more kids, the other kids are miserable as well. Don't forget how miserable the husbands are, right, with having a baby and a severely mentally ill wife. And this group is not mentioned a lot, but I think there is a huge pain and struggle for partners, men or women, but in most scenarios, it's a man. They struggle as well. And, so it's really a larger problem.
Puder:
So, okay, we're pushing this idea of a mother-baby unit and somehow we have to figure out how to make it work in our insurance model, which is awful. And to do that, we first probably need someone to donate to you or to your team, maybe three teams across the US, ideally. And then do some good research that shows the cost-effectiveness of it. And then subsequently, there's some justification maybe. That's how it works in the US. We did a money justification study of my IOP (intensive outpatient) program. We had medically complex adults, so people with lots of medical admissions for psychosomatic illness, and we found that we were able to cut the amount of money that insurance would spend, after the program, compared to the year before.
Puder:
And we use this to argue with insurance companies to let us actually treat the patients, right? And sometimes it worked.
Bergink:
Oh, wow. So you're the person. As one of the first steps we should hire you, as well. Right?
Bergink:
You're quite busy, I think.
Puder:
I could give you the name of the guy that did the majority of the study, at least.
Bergink:
Yeah. Yeah. No, any help is welcome.
Should Postpartum Psychosis Be Added to the DSM? (36:13)
Puder:
So we… Okay, so we're talking about the mother-baby unit, but I also wanted to make sure… the DSM. I understand you are the ringleader of this new push for this to be introduced in the DSM. You're writing the chapter, you sent me an outline of it. Do you want to mention what you're doing with this? And maybe I'll show… I'll bring it up so you can….
Bergink:
Absolutely. So postpartum psychosis is a disease that exists, that has been among us, unfortunately, for thousands of years, among all cultures. So, simply said, very weird that it doesn't exist or it's not acknowledged. It's for us, doing research, a clear phenotype, mainly that you can define it well, that given the onset is so clear. So there is a large push from psychiatrists, but also patients, to have this in our classification system. And, we started working on this six years ago, sending in a proposal that has to have all kinds of criteria. It was, like, 30 pages long. And since then, it just hasn't moved fast enough. It's now six years. There is full agreement among all health professionals what the criteria should be like. There's also flexibility as in we're not rigid, and all patients' organizations bought in on this idea, so it just has to happen.
Bergink:
We proposed postpartum psychosis to be placed in a bipolar chapter. The DSM steering committee said, "We would like to see an entire chapter dedicated to childbirth." So we made an outline, again, with a very large group of people who worked a lot clinically, and also research leaders to make a childbirth-related chapter in DSM and give an outline of what that should look like. And I think it's important that, what we would like to see as a field is to make sure that people can classify the onset of any disorder, either being during pregnancy or the first three months after delivery, and that is important because those periods are very different in terms of biology, but also treatment. I mean, that's a bit of a no-brainer, right?
Bergink:
Pregnancy's very different from postpartum, but also the prevalence and incidence is sometimes different. So, well, anyway, and in addition to that, I think, given that depression is so common, we would like to see depression with onset during pregnancy and depression with onset within three months after delivery as a separate possibility to classify. And then the most important thing, and how this all started, and because that is really going to prevent a maternal death, is having postpartum psychosis in there. Of course, if it's classified, it doesn't immediately solve all the problems, but it's kind of the other way around. If this is not solved, then as a first step, we need to classify to speak the same language, right? So, to have the criteria, and members of the DSM steering committee even said, “They can write research proposals without criteria,” but that's a bit of a nonsense argument because, you know, in order to do studies, but also to replicate each other's work, we need to do the same thing and speak the same language.
Bergink:
So I think it's a problem that there are so few groups working on this. That I'm telling you all those things, and that is then taken as the truth. Whereas, in real science and in medicine, ideally, studies get replicated and replicated and clinicians add to evidence and then you can build solid guidelines, which people can follow. And all those steps need to be taken. So we're… I said before, we're in the middle ages, and I might regret some things I have said in public, but that's not one of them, because that's really how I feel about it.
Puder:
Yep. Yep. And I think what we need is an ICU-level billing code that comes along with this. You know, there's inpatient stays, but a mother-baby unit should be an ICU-level billing stay. That is, it should be a level above, right?
Bergink:
Absolutely.
Puder:
I think that's where I would go for….
Bergink:
And that's totally justified because it's complex care, right? I mean, we have a severely ill mother.
Puder:
And you have an infant, so you need a nurse for the mother, a nurse for the baby, and you need to watch them 24/7, so that the infant is not hurt.
Bergink:
I know, but honestly, the infant is, of course, separated from the mom during the night. The door is closed. So I have to say, Europe and the UK, we also have medical students looking after the babies, because they're babies. Beautiful. They're healthy babies. But I'm not sure if that is even, you know, I don't know the US healthcare system well enough to see if that would fly, but that makes, of course, also a difference in terms of funding.
Puder:
No, they would volunteer for it.
Bergink:
Yeah, I would volunteer for it. Yeah, maybe not if you just have your young children, but this, for me, it's a long time ago. Many people volunteer looking after healthy babies.
Puder:
Oh, they would. It would be a great sublimation of the delay, the natural delay that medical school requires for a lot of people, right, of having their own infants.
Bergink:
Well, I still think it's also helpful if doctors get children at some point in their career.
Puder:
Right, right. Yeah, I mean, absolutely. Yeah. And I'm not saying otherwise,
Bergink:
No, no. But, I know what you mean.
Postpartum OCD, Intrusive Thoughts, and PTSD (42:41)
Puder:
But, okay, so DSM. I'm surprised OCD isn't in this list, here. Like, postpartum OCD. I don't know if that's….
Bergink:
Yes, because it's extremely rare, honestly. So OCD doesn't have a big postpartum [onset]. Everyone gets a bit more obsessed biologically after childbirth. So, you know, mothers check on their babies a few times. That's all very physiological. I think nature built that into, to have the most relaxed, you know, not so spot-on persons have taken care of their child well. And also, everyone gets a bit more obsessive during this period, and we see that, you know, women who are very perfectionistic, always function well at other times, sometimes struggle with that because then they feel even more the need to be in control or to check on things. So that is what we see, that women with high perfectionism are at sometimes a higher risk of postpartum depression. And our research showed that as well. And we see that women with OCD already diagnosed with OCD sometimes have more symptoms, but not always.
Bergink:
But actually, new onset postpartum OCD is very rare. I've only seen a few women in my lifetime. So, obsessive thoughts are very common but first onset OCD is quite rare. So that is why we did not specify so many other disorders. Also, for example, PTSD, right? Some women have trauma after childbirth. Their delivery was horrible, and they do not only have trauma, they also have nightmares and flashbacks. But that is also quite rare. We see that most women who struggle in this period are women who already had trauma, who had PTSD in [their] history. And in women, that is often related to sexual trauma, unfortunately, right? So, and we see that makes sense then because the delivery is, you know, people re-experience sometimes that loss of control that they had in their lives before, and that can evoke trauma.
Bergink:
But that is, in many cases, not new onset PTSD. So that is why other disorders such as OCD and PTSD, we saw that it was better served by being able to specify the onset for any disorder. You see what I mean? So, mental health disorder during pregnancy, PTSD with onset during pregnancy, or PTSD with onset postpartum, same for OCD. So we propose that in our document as well. And the reason to take depression separately is that there has been so much done, so much research on depression specifically, so there's a much larger evidence base. And another reason is that there is a big peak of incidence of depression cases. And especially, there is a peak in severe depression. So that is really a thing if you look in epidemiological studies.
Puder:
Very good. That's very helpful. Wow. You're such an expert on this, and I can feel it. I don't know if you're always this energetic, but I feel like your hyperthymia, your Roosevelt or Kennedy level of energy.
Bergink:
Oh, wow! That is tricky to speak with you as a psychiatrist. Before I knew it, I got a diagnosis on the spot.
Puder:
No, no, no. As a compliment. Hyperthymia is a compliment.
Bergink:
And then to answer your question. No, I'm not always that energetic. But if I know that I'm doing a podcast, then yes, I am. And, with regards to this topic, I am very passionate and that's sometimes also very unfortunate because I can't let it go, right? So I sometimes feel like, okay, it would be good for me if I now focus on something else and not the classification of postpartum psychiatric disorder. And I've also been working on postpartum psychosis now for 22 years and sometimes I feel like, okay, it would be good to not do it. But yeah, I don't know how to do it, David. So any tips there are welcome.
Puder:
I would say it's meaningful. It hits all the meaning buttons, you know? So, we talk about logotherapy sometimes in the podcast [see episodes 32 and 113], Viktor Frankl, finding one's purpose, one sense of meaning. And it's like if you get to the end of your life and you can look back and realize that there's a lot of, you know, there's a ripple effect of impact that you've had, I think solving one issue is enough for a lifetime, right? Uh, and this is an issue you're solving.
Bergink:
Yes, and maybe that's because I feel that it's really solvable, right? So that's why I might not be thinking about the other important themes such as saving climate change or all the worlds in the world, because those are all very unfeasible for a human being, and that I feel this is so, well, I won't say easily done, but it's really doable. Things such as changing classification are doable and things such as building a mother-baby unit. Those are not impossible things. And the same for I feel if women at high risk for postpartum psychosis hear, or their doctors, how they can prevent it, that's also relatively easy, right? It's not difficult to prevent postpartum psychosis. And because it's so relatively easy, I feel like we should do it and get the word out.
Puder:
Well, maybe the harder part is the education and the implementation, right? So I hope, in some small part, the four episodes that I put out on this can help.
Bergink:
Yes, that hugely helps. Thanks a lot for doing that.
Puder:
I think this episode, in particular, is especially helpful, and I'd love to have you back in the future. Any final thoughts that you want to get out? Anything that you haven't mentioned that you want to make sure is out there?
How to Prevent Postpartum Psychosis in High-Risk Women (49:11)
Bergink:
Yes. I want to make sure that women at high risk with bipolar disorder or with a prior history of postpartum psychosis know that if they have another child, that they really can prevent it by taking medication right after delivery. And that we really can prevent postpartum psychosis. I think that is the most… you can forget everything else, but that's the most important take-home message.
Puder:
So, do you start the lithium towards the end of the third trimester, or do you start it on the day of delivery?
Bergink:
Yes, we say, "Baby out, lithium in."
Puder:
Oh, okay.
Bergink:
That's easy, you know, talking about education, if you're a high risk, then that works well.
Puder:
Baby out, lithium in. Okay, that's great.
Bergink:
If you're at high risk, right? It's not for everyone. Yes.
Puder:
Awesome. Okay. All right. Thank you so much for your time. Thank you. We'll have you back in the future. I love talking to you.
Bergink:
Yes, thank you for having me. Bye.
Puder:
Bye.
Additional Pregnancy and Postpartum Episodes
Episode 013: Postpartum Depression with Dr. Pereau
Episode 033: Perinatal Mood and Anxiety Disorders
Episode 184: Pregnancy Planning for Patients Taking Psychiatric Medications or with a Mental Health History
Episode 276: Postpartum Psychosis: Symptoms, Warning Signs, Risk Assessment, and Treatment with Dr. Furey and Dr. Puder
Episode 278: Postpartum OCD vs Postpartum Psychosis: Intrusive Thoughts of Infant Harm, How to Screen, and Lithium Prevention with Dr. Katie Unverferth
Episode 279: Postpartum Depression and Problem-Focused Psychodynamic Psychotherapy: Understanding the Five Core Conflicts
References
Bergink, V., Armangue, T., Titulaer, M. J., Markx, S., Dalmau, J., & Kushner, S. A. (2015a). Autoimmune encephalitis in postpartum psychosis. American Journal of Psychiatry, 172(9), 901–908. https://doi.org/10.1176/appi.ajp.2015.14101332
Bergink, V., Burgerhout, K. M., Koorengevel, K. M., Kamperman, A. M., Hoogendijk, W. J. G., Lambregtse-van den Berg, M. P., & Kushner, S. A. (2015b). Treatment of psychosis and mania in the postpartum period. American Journal of Psychiatry, 172(2), 115–123. https://doi.org/10.1176/appi.ajp.2014.13121652
Bergink, V., Kamperman, A., & Robakis, T. (2025). Duration of episode in postpartum psychosis treated with antipsychotic medication and lithium. American Journal of Psychiatry, 182(12), 1094. https://doi.org/10.1176/appi.ajp.20250755
Sharma, V. (2006). A cautionary note on the use of antidepressants in postpartum depression. Bipolar Disorders, 8(4), 411–414. https://doi.org/10.1111/j.1399-5618.2006.00336.x